The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Attempt to deescalate the client.

Continue to observe the client for increased agitation.

Offer medications to help the client control behavior.

Ensure safety in the environment for the client and others.

Answer and Explanation

The Correct Answer is D

A.   Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B.   Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C.   While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D.   Ensuring the safety of the client and others is the priority in situations of escalating agitation.

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Correct Answer is ["A","C","D"]

Explanation

A. Establish a healthy sleeping, eating, and exercise routine This is an important relapse prevention strategy as it promotes physical and emotional wellbeing. A structured routine helps maintain stability and reduces the risk of returning to substance use.

B. Prevent overscheduling and becoming fatigued and exhausted. Reach out to reconnect with old buddies to test strength in resistance This statement includes potential triggers for relapse (reconnecting with old buddies) and does not align with effective relapse prevention strategies.

C. Have a friend or counselor number to call when having doubts This is a valuable strategy as it provides the client with a support system and someone to reach out to during moments of doubt or vulnerability.

D. Attend outpatient and community support groups for addiction Support groups provide a sense of community, understanding, and accountability for individuals in recovery. They offer a safe space to share experiences and coping strategies, making them an essential part of relapse prevention.

A. Have the client go to his room until calm. B. Politely ask the client to stop talking. C. Speak slowly and in a quiet voice to help the client focus. D. Encourage the client to talk more so you can determine what he is thinking.

Correct Answer is C

Explanation

A) Incorrect. Isolating the client in his room may escalate the situation or make the client feel isolated and misunderstood.

B) Incorrect. Asking the client to stop talking may be perceived as confrontational and could potentially agitate the client further.

C) Correct. Speaking slowly and in a quiet voice can help the client focus and may reduce the flight of ideas. This calm approach can be grounding for the client.

D) Incorrect. Encouraging the client to talk more may exacerbate the flight of ideas and the manic state.

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The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is building a discharge teaching plan with a client diagnosed with substance use disorder. Which of the following relapse prevention strategies will be included in the teaching? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is C

Explanation

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